Behavioral therapy for premature ejaculation has little evidence to support its continued use for the indication, authors of a systematic review concluded.

Action Points

Note that premature ejaculation is a frequent sexual dysfunction; psychological issues are present in most patients but it is not clear that these issues are causative.

Note also that this review was designed to evaluate the current literature concerning therapeutic effectiveness of psychological interventions.

Point out that the review concluded that there is only weak and basically nonsignificant evidence for the effectiveness of psychological interventions.

Behavioral therapy for premature ejaculation has little evidence to support its continued use for the indication, authors of a systematic review concluded.

A handful of published studies showed "weak and inconsistent evidence" that psychological therapies improve any major endpoints related to premature ejaculation.

The results fell far short of the 97.8% success rate for psychological intervention reported by pioneering sex researchers Masters and Johnson, investigators reported in the Cochrane Database of Systematic Reviews.

Still, a coauthor of the report held out hope that psychological interventions will eventually prove beneficial.

"We need to do more to prove it works," Stanley Althof, PhD, of the Center for Marital and Sexual Health in West Palm Beach, Fla., said in a statement.

The review included four studies with a combined total of 253 patients. Investigators in the studies employed similar techniques and did not include a number of therapies that could be helpful, Tamara Melnik, PhD, of the Federal University of Sao Paulo in Brazil, and coauthors noted in their discussion.

A substantial proportion of men have premature ejaculation, as estimates of the prevalence have ranged from 3% to 20% according to the definition used. Use of a strict definition -- a latency of less than 60 seconds after vaginal penetration -- results in a prevalence of 2% to 5%, according to Althof.

The etiology of premature ejaculation remains poorly understood, and potential explanations run the gamut from psychosomatic manifestations of anxiety to dysfunctional signaling involving the 5-hydroxytryptamine (5-HT) pathway, the authors noted in their introduction.

The 5-HT theory has support in reported successful treatment of premature ejaculation with selective serotonin reuptake inhibitor (SSRI) antidepressants, which modulate 5-HT signaling, the authors continued.

Many psychological interventions have their origin in the conceptualization of premature ejaculation as a "conditioned reflex," possibly resulting from repeated episodes of hurried masturbation or sexual intercourse by individuals who fear being caught in the act.

Masters and Johnson advocated the "squeeze technique," which requires the man's sexual partner to squeeze the base of the penis repeatedly to delay ejaculation, possibly leading to increased latency. People who completed a two-week program in the technique had near-100% resolution of premature ejaculation (Human Sexual Inadequacy, Little & Brown, 1970).

Other sex researchers and therapists reported similar high rates of success with various behavioral and psychological interventions. However, virtually all of the data came from case reports or clinical series.

To see how well psychological interventions fared in the setting of a randomized controlled trial, Melnik performed a systematic review of multiple databases and identified four studies suitable for inclusion.

All of the studies had a randomized or quasi-randomized design and compared a psychosocial intervention with another psychosocial intervention, drug therapy, waiting list, or no treatment. The primary outcome was improvement in the intravaginal ejaculatory latency time (IELT).

Three of the studies produced positive results, but the fourth had insufficient data, Melnik and colleagues reported.

One study demonstrated superiority for behavioral therapy and a "functional-sexological treatment" versus a waiting list. Another found the combination of behavioral therapy and chlorpromazine superior to chlorpromazine alone. The third positive study showed that citalopram led to greater improvement in IELT than did behavioral therapy.

The incomplete study evaluated four different drugs (three antidepressants and a phosphodiesterase type 5 inhibitor) used on an as-needed basis 35 hours before anticipated sexual activity, or they were instructed to use a variation of the squeeze technique. Patients completed five four-week assessments, one for each intervention.

Each of the studies reported a variety of secondary outcomes, which were not consistent among the studies.

Although three of the four studies yielded positive results, the authors were unimpressed.

"The vast majority of reported outcomes did not reach statistical significance; thus, the clinical effectiveness of the few included studies is questionable," they wrote in their summary.

"The results of the reviewed trials yield inconsistent and poor conclusions regarding the effectiveness of psychotherapy," they added.